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stinastina

Help with Novolog and Lantus

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stinastina

So I just started insulin this week and my doc gave me some guidelines. I tried to write everything down but I may have missed something.

 

So I test 5 times a day and if bg>110 I take 3 units of Novolog and +1 if >150, +2 if >200. Last night I had some mashed potatoes that I made with butter and sour cream. I went from 133 before dinner to 220 before bed. So before bed I am only supposed to take 1 unit of Novolog. Since I was so high, I decided to take 5 and eat some chia pudding I made (with chia seeds, xylitol and heavy cream). In the morning I was 208. Once I have coffee, my morning number drops before breakfast.

 

If a person is high before bed, is it okay to take Novolog (even if I don't eat) ? And should I take it like I'm eating ? In the morning, if I'm still high when I wake up, do I take more or just wait until before breakfast ?

 

I'm supposed to up my lantus by 2 units every 3rd day if I am over 130. 

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Uff Da

Let's see if I understand this correctly. Your plan is based upon testing five times a day. But it is based upon eating three times a day. You are to correct at meal time according to the figures given. No information was given to you about correcting or eating at bedtime.

 

The amount of insulin you take is the same at each meal, 3 units. That means the doctor expects you to eat the same number of grams carb at each meal. How many carbs are you supposed to eat?

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stinastina

If I'm over 150, I take 1 unit at bedtime.

 

I'm not counting carbs - they call this a sliding scale. I just got out of the hospital last week with dka so the treatment is insulin. They say this won't be long term and supposedly I go back to metformin and glimepiride after a month or so. I think they were worried I was not producing my own insulin.

 

I try to eat low carb most of the time but last night I made the potatoes and ate them. Bad idea. I don't like the idea of being >200 all night. So I was wondering what I could do, given the information they gave me.

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Uff Da

If you are high before bedtime, I'd expect you would probably use the same correction additions that you do at a meal. So if you don't also eat, take 1 unit if you are over 150, 2 units if over 200, etc. However, I'd be a little leery to sleep through the night the first time with correcting to a target of 100. After you see if the dose your doctor gave you as a starting number isn't too high, it would be safe. Personally, I'd set the alarm and get up about three hours after correction bolus the first night, if I was trying for 100 by morning just to make sure I wasn't going low. Once you see if the dose is okay or if you need a little more, it will be easier to do safely.

 

Even if you are on a sliding scale, it would be nice to know how many carbs the doctor is basing the scale upon. That would give you a better idea of what to dose if you want a small snack at bedtime without having to eat a whole meal equivalent.

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Uff Da

The more I think about it, I think you are really going to have to avoid a bedtime snack until you get your Lantus dose corrected. The general idea of the basal is to set the dose so your morning reading is approximately even with your bedtime reading and no more than 130. Your bedtime reading should ideally be at least five hours after your last food and meal time bolus, because food can take that long to digest and Novolog stays in the system a long time. If you eat more at bedtime that will mess up your basal testing overnight. If you need to, just take a correction dose without the extra for a meal. Once you get your basal dose set correctly, then you can have a bedtime snack if you like.

 

You also asked, "In the morning, if I'm still high when I wake up, do I take more or just wait until before breakfast?"  Personally, I always take the correction with the meal bolus. That way you don't have two injections that have overlapping time periods. Remember the insulin stays in the system for five or six hours. So it gets rather complicated having to calculate how much of the previous insulin injection is still in your system. If you do have to stay on insulin long term, you can get into that months down the road, but I sure wouldn't do it for a possible short term regime.

 

 

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stinastina

I usually have dinner maybe a couple of hours before bedtime. I get up, have coffee. Then I have breakfast late sometimes close to 12. lunch around dinner time and dinner close to bed time. You see I have no idea what I'm doing and why. I will try to readjust and eat something with my coffee and call it breakfast. Then eat lunch around noon and dinner no later than 7pm. But I may need a snack before bed. :)

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Uff Da

LOL. I always have to have my snack before bed. Before diabetes I used to get up in the middle of the night and eat almost every night.  My endo didn't think too much of that idea.  

 

After you get your insulin doses adjusted, you can change your schedule to whatever works best for you. What I really hate is feeling that I need to stay up for at least four hours after dinner bolus to get a really good idea of what my BG will be for the night. If I repeated the same foods exactly more often, I would know how much insulin it would take, but we tend to be "creative cooks" and rarely make exactly the same food twice. So it is easy to be far off in my carb counts at times. We've moved our dinner to 5 PM, so I can have a fair idea of night time BG by 9 PM. Then I make my bedtime snack something really easy to count carbs on, like nuts or cheese (or both!) so if I need to bolus any extra, I won't be far off.

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Hammer

So I just started insulin this week and my doc gave me some guidelines. I tried to write everything down but I may have missed something.

 

So I test 5 times a day and if bg>110 I take 3 units of Novolog and +1 if >150, +2 if >200. Last night I had some mashed potatoes that I made with butter and sour cream. I went from 133 before dinner to 220 before bed. So before bed I am only supposed to take 1 unit of Novolog. Since I was so high, I decided to take 5 and eat some chia pudding I made (with chia seeds, xylitol and heavy cream). In the morning I was 208. Once I have coffee, my morning number drops before breakfast.

 

If a person is high before bed, is it okay to take Novolog (even if I don't eat) ? And should I take it like I'm eating ? In the morning, if I'm still high when I wake up, do I take more or just wait until before breakfast ?

 

I'm supposed to up my lantus by 2 units every 3rd day if I am over 130. 

I can't believe that doctors are still prescribing the sliding scale method.  As you can see by what your doctor prescribed, the sliding scale method waits to see how high your BG levels go, then you take insulin to bring those levels back down.  The carb counting method has you count the carbs in the food, then you dose based on that, that way, you don't go high in the first place.  Going high is never good for you, and the sliding scale method is constantly having you go high before dosing.

 

Your doctor has no idea how much insulin you still produce, or what your level of insulin resistance is, not to mention that your insulin resistance changes throughout the day.  For him to tell you take X amount of insulin without knowing these things, is just having you take a stab in the dark.  I've always felt that doctors would prescribe the sliding scale method because they felt that taking some insulin is better than not taking any, even if the amount you take doesn't help much.  By not counting carbs, there is no way that a person can determine the correct dose to take.  If you test and you are at 220, like you mentioned, using the sliding scale method, you would have take 3 units of Novolog since you are over 110, then 2 more units since you are over 200, so you'd have to take 5 units of Novolog, but that doesn't take into account what you are about to eat.  If the food you ate spiked you by 50 points, then the 5 units of Novolog would only be enough to work on the 220 BG, and it wouldn't be enough to cover the additional 50 point spike, so using the sliding scale method, you are always playing catch up, but you never will catch up, you will always be behind. 

 

Look at it like this....let's say you went to someone's birthday party and ate some cake, ice cream, potato chips, and drank a sugared soda.  When you got home and tested, you could well be over 400, so you'd then need to take a bunch of Novolog to try to get that level down.  Does being over 400 sound like a good place to be?  Using the carb counting method, it's very possible to eat those foods, although not recommended, but before eating them, you'd take the appropriate amount of Novolog, then, when you got home, it's very possible that you'd be under 200....probably under 150.  Which scenario sounds better?

 

If you first get up in the morning, and your BG is higher than you want it to be, and that is a personal decision (I want mine to always be in the 70's, but others may want it a bit higher), then that means that your basal insulin (Lantus) needs to be increased until you get that morning BG down to your preferred level.  As for the Novolog, well, the method of dosing (sliding scale or carb counting) is up to you, so you need to do what you think is best for you.  I will say that from reading posts from others using Novolog, if you find that your dawn phenomenon is causing you to wake up with higher numbers than you want to be, you could try taking a unit or two of Novolog before bed to keep the DP from having much effect on you, but you'd have to experiment with that.  I don't have DP, so maybe those here that do have DP and use Novolog could answer that.

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NoraWI

A very good explanation, Hammer. With the information given, I would ditch the sliding scale AND the doctor and find one who endorses the logical carb-counting method. I, too, can't believe there are still doctors out there who are foisting the sliding scale on their patients.

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stinastina

A very good explanation, Hammer. With the information given, I would ditch the sliding scale AND the doctor and find one who endorses the logical carb-counting method. I, too, can't believe there are still doctors out there who are foisting the sliding scale on their patients.

 

Except I am on the sliding scale because the treatment for dka is low doses of insulin. The way they explained it to me is I have to go up slowly because they felt the Farxiga was lingering in my system even after I stopped taking it 2 weeks prior. They were still finding lots of sugar in my urine when I was discharged the Friday before last.

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Hammer

I am by no means an expert on DKA, so maybe someone who has more knowledge about it can chime in here.  My understanding of DKA is when there isn't enough insulin in the body to help transfer the glucose into the blood cells, the body begins breaking down the fat stores in the body for fuel, which produces a byproduct called ketones.  If you are injecting less insulin than you need, that seems like it would be counter productive to the body's need for more insulin, unless the lingering effects of the Farxiga are causing your body to dispose of the extra glucose in your urine, so much so that you have a lot less glucose in your system for the insulin to work on.  Again, I am no expert here, so my understanding of this may be off base.

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stinastina

I think you are thinking of ketosis - when you eat less than 20g carbs per day and your body breaks down fat for energy. Dka is when ketone acids build up in your blood. I was taking farxiga which flushes glucose out through urine. My bg numbers weren't "high" and the drug I was taking caused the acid to build up, I became dehydrated, potassium and phosphate were low and there was a problem with my anion gap and beta hydroxybutyrate levels. Once they got the acid out of my blood, and hydrated me, they started me on an insulin drip of 1 unit per 24 hours to improve the beta hydroxybutyrate levels. I bounced back between step down and the regular floor a couple of times because they could not get the numbers in the normal range. The day before I went home, they put me on lantus and told me I would need to take it for at least a month since I was still spilling sugar.

 

The FDA just made Astra Zeneca update the label in December to include dka.

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TX_Clint

I have been taking some form of this medication for over 2 years with no complications at all. I guess I'm just one of the lucky ones. It really does work for me and you can't beat free. I started with invokana and when the free ride ended I switched to jardiance. I feel for anyone that gets dka and hope you don't have those issues again Stina.

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stinastina

I have been taking some form of this medication for over 2 years with no complications at all. I guess I'm just one of the lucky ones. It really does work for me and you can't beat free. I started with invokana and when the free ride ended I switched to jardiance. I feel for anyone that gets dka and hope you don't have those issues again Stina.

 

Thank you, Clint ! I would just advise you have regular bloodwork and urinalysis. I was taking it for a year with I thought no problems but my doc said I was sick for a while. The only symptom I had was extreme fatigue. So it builds up in your system over time. Mine finally broke at the one year mark.

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stinastina

So for my own edification, how do you use Novolog when counting carbs ? Do you count protein as well ? I have 3 weeks before I go back to the doctor and I don't like the numbers I'm at. But I suppose once I get the lantus to the right dose, will my numbers come down ? Right now I'm at 18 but for my weight I'm supposed to be around 24. I can only go up 2 units every 3rd day if I am consecutively over 130. 

 

I feel like you really need to be a genius to get this stuff right - it is very complicated. Do any of you prefer to split your basal dose ? Is it true that in the evenings we become less sensitive to insulin and do you adjust your dose of bolus or basal accordingly ?

 

I'm having difficulty eating at regular times. I may just have to set a timer and and stop and eat until my numbers come down.

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JohnSchroeder

The Lantus should just keep you steady, not really bring you down.  That's what the Novolog is for.  You need to have some idea of how much your blood sugar goes up due to eating carbs.  If for example you eat 25 carbs, maybe your blood sugar goes up 50pts.  Then you also might know that it takes roughly 4units Novolog to cancel out those carbs.  So the Insulin:Carb ratio would be 4:25, simplified down to 2:12.5 or 1 unit of insulin for every 6.25 carbs.

 

Probably aught to round for easy measuring though.  If my make believe numbers were real, make it 1 unit for every 6 carbs you eat.  Preferably taken at or before eating.

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Hammer

So for my own edification, how do you use Novolog when counting carbs ? Do you count protein as well ? I have 3 weeks before I go back to the doctor and I don't like the numbers I'm at. But I suppose once I get the lantus to the right dose, will my numbers come down ? Right now I'm at 18 but for my weight I'm supposed to be around 24. I can only go up 2 units every 3rd day if I am consecutively over 130. 

 

I feel like you really need to be a genius to get this stuff right - it is very complicated. Do any of you prefer to split your basal dose ? Is it true that in the evenings we become less sensitive to insulin and do you adjust your dose of bolus or basal accordingly ?

 

I'm having difficulty eating at regular times. I may just have to set a timer and and stop and eat until my numbers come down.

You should not base your Lantus dose on your weight.  I've heard others here say that they were told the same thing, which makes no sense to me.  When I started on Lantus, I was told to start with 8 units every night, and if that didn't bring down my fasting BG levels, then every three days, increase it by two units.  I did that at first, but when I wasn't seeing any results, I upped the dose by five units instead of two, and I only waited two days instead of three.  As I finally got close to the dose I needed, there was a noticeable drop in my fasting BG levels.  Once I saw that drop, I went back to increasing my dose by only two units.  Then, once my fasting BG dropped below 100, I increased my dose by one unit until my fasting BG dropped into the 70's, which is where I wanted them to be.  At that point, I was taking 156 units of Lantus every night. :eek:

 

As for the Novolog, I started out taking one unit of Novolog for every 18 carbs I was about to eat.  I would test my BG before I ate, then two hours after I ate.  The idea was to have my after meal BG be close to my before meal BG.  If my after meal BG was too high, then at the next meal, I'd take one unit of Novolog for every 16 carbs I was about to eat.  I'd keep doing that...taking one unit of Novolog for a lessor amount of carbs until I got an after meal reading that was close to my before meal reading.  Once you get to that point, that will be your insulin to carb ratio. You don't want your after meal reading to be lower than your before meal reading, that would mean that you took too much insulin.  The thing is, that ratio will change, so it's good to test often.

 

The thing with taking a bolus insulin like Novolog or Humalog, is that you need to test frequently until you begin to see how it affects your BG levels when you eat different foods.  When I first started on Novolog and found my insulin to carb ratio (I:C ratio), I thought that meat should be okay to eat since it doesn't have any carbs.  When I would eat meat, I saw that my BG levels would rise, so I began experimenting and decided that I would take a few units of Novolog when I ate meat to prevent that rise in my BG levels.

 

I know it all sounds complicated, but what you will find is that, over time, you'll just know how much Novolog to take when you eat certain foods.  My usual dinner is a large salad that I buy at the food store.  When I eat it, I know that I'll need to take 13 units of Novolog, since that's what I've been taking whenever I eat this salad.  I don't even bother to look at the carb content anymore, I just know to take those 13 units.  The same will happen with you.  It'll be like, "I need to take X amount of insulin when I eat XX amount of food A.  I need to take Y amount of insulin when I eat YY amount of food B.  I'm going to eat both food A and food B, so I combine the amount of insulin I need to take for each one, and inject that."  As you begin to learn how much insulin to take for each individual food (maybe keep a log), eventually you won't need to count carbs in those foods that you frequently eat, you'll just know how much insulin to take.  If you don't know the carb content of the food, just Google it.  Just type in the name of the food with the word nutrition after it, like "carrots nutrition".

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stinastina

Thank you, both.

 

Let me make sure I got it. Lantus is to be increased until I get my fbg in the right range. I did a little experimenting today and adjusted the novolog to what I was going to eat. I really only needed 2 or 3 more units. What a difference that made ! My last prick was 134. 

 

I appreciate all the help. 

 

Hammer, as far as I:C ratio goes, how did you figure yours out ? I am guessing this will be different for everyone, depending on your insulin resistance ?

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Hammer

Thank you, both.

 

Let me make sure I got it. Lantus is to be increased until I get my fbg in the right range. I did a little experimenting today and adjusted the novolog to what I was going to eat. I really only needed 2 or 3 more units. What a difference that made ! My last prick was 134. 

 

I appreciate all the help. 

 

Hammer, as far as I:C ratio goes, how did you figure yours out ? I am guessing this will be different for everyone, depending on your insulin resistance ?

Yes, you increase your Lantus until you get the fasting BG levels you want.

 

Figuring out your I:C ratio is fairly easy.  As I mentioned in my post above, start out by taking one unit of Novolog for every 18 carbs you are about to eat.  If you calculated the carbs in the food you are about to eat, and they came to 20, well that's okay, you'd still take just one unit of Novolog.  You need to test before you eat the food, then test again, two hours after you've eaten.(don't wait three or four hours to test, test at the two hour mark.  You can still test three and four hours after you've eaten to see how your numbers are trending, but the two hour mark is more important.)  Now let's say that before you ate. your BG was at 85.  When you tested two hours after you've eaten, you found that you're at 130.  That's too high, you should be closer to 85, like maybe 100.

 

Okay, at your next meal, test before you eat, count the carbs in the food, then take one unit of insulin for every 16 carbs you are about to eat.  Test two hours after you've eaten, and see if your after meal numbers are close to your before meal numbers.  The after meal numbers don't have to be exactly the same as your before meal numbers, but they should be close.  If your after meal numbers are still too high, then at your next meal, take one unit of insulin for every 14 carbs you are about to eat.  If you find that at the two hour after meal reading you are still too high, then at the next meal, take one unit of insulin for every 12 carbs you are about to eat.  You keep repeating this....taking one unit of insulin for every 10 carbs you are about to eat....one unit for every 8 carbs you are about to eat, etc., until your after meal numbers are close to your before meal numbers.  If you find that your after meal numbers are lower than your before meal numbers, then that means that you took too much insulin.  You don't want your after meal numbers to be lower than your before meal numbers.

 

Once you find that your after meal numbers are close to your before meal numbers, the amount of insulin you took for the carbs in that meal will be your insulin to carb ratio.  If you ate 20 carbs and took 2 units of insulin, then that means that you'd need one unit of insulin for every ten carbs you ate, so your I:C ratio is 1:10....one unit of insulin for every 10 carbs.  In my case, my I:C ratio is 1:2½, or 1 unit of insulin for every 2½ carbs that I eat.

 

Keep in mind that most people's insulin resistance seems to change throughout the day, so that means that your I:C ratio will change throughout the day also, but the way to deal with that is to take a smaller dose of insulin to err on the side of safety until you become familiar with how your body's insulin resistance changes throughout the day.  If you find that your after meal BG is higher than you'd like it to be, you can always take a second, corrective shot to get it down.  My insulin resistance seems to remain the same throughout the day, so my I:C doesn't change.

 

Another thing that you'll find....if you gain or lose weight, that will affect your insulin resistance also.  If I gain or lose just one pound, it's reflected in my BG numbers.  The nice thing about using insulin is that, once you become familiar with how it works in your body, you can obtain precise control of your BG levels.  If I gain weight, as I see my BG levels rising, I just increase my Lantus dose to get those numbers back down.  If I eat food that I'm not sure of the carb content, I'll guess at what it might be, and two hours after I've eaten, if my BG levels are higher than I like, I'll just take a corrective shot of Novolog and in about an hour, those levels will drop down.

 

I was at a friend's house for dinner, and I wasn't sure of the carb content of the food, so I took a little less Novolog than I thought I needed.  Two hours after I had eaten, I tested again, and I was at 180....way too high for me, so I took a corrective shot, and 90 minutes later, I was in the 80's.  Just make sure that you keep some glucose tablets close by in case you take too much insulin and start to go low.  I keep a 10 pack of them in my pocket, and I have a bunch of them stored in zip lock bags in each of my cars, as well as bottles of them in every room in my house.  You could use candy in place of the glucose tablets, but the glucose tablets contain exactly 4 carbs per tablet, plus, storing them in your car won't hurt them, whereas candy would melt in the hot summer months.

 

Now, to throw a monkey wrench into the mix, not all foods will release glucose into your system at the same rate.  If you eat something like pizza, the fat in pizza will slow down the release of glucose, so you might not see a peak in glucose levels until 3-4 hours after you've eaten it, so if you had taken the correct amount of insulin, the insulin would start to work before the glucose is released.  The thing here is to test....test...test.  Of course, we shouldn't be eating pizza in the first place, but I just wanted to make you aware of this so that you wouldn't be caught off guard, should you eat some high fat, carby food.

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Uff Da

Be aware that the duration of action of the fast-acting insulin (Apidra, Humalog, and Novolog) is up to 5 hours. The duration may vary from day to day. A low dose will likely be used up faster than a larger dose. But don't count on any of them getting you back to pre-meal level in two hours until you've done a lot of experimenting. I know Hammer says it happens for him, but from what I hear from others, that is more the exception than the rule.

 

Usually with Apidra I could have a fairly good idea after three hours of where my BG would land for the night, so I could take a bedtime reading  three hours from dinner basal and if my reading was around 100, I could feel safe to go to bed. Of the times I tested at 3 hours and again later, it usually only dropped another 10-15 points, but until last week the worst additional drop after three hours was another 35 points. But last week I took a reading at 4 hours 5 minutes, then again about 6 hours from bolus. It had dropped an additional 50 points! Glad I didn't go to bed after a 3-hour test that night!

 

For me Novolog took the longest. There was one time it dropped an additional 59 points after the 4½ hour point.

 

All of these tests were with a dose of either 7 or 8 units.

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Tjustice

Have I told you guys today how informative and helpful every one of you are? Well, you are.... Thankyou

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stinastina

Hammer, how do you determine how much to take for a corrective dose ? I did buy some glucose tabs just in case. 

 

So today I will be checking 2 and 4 hours after meals to see how Novolog acts on me. I wish I could eat the same things everyday but I just can't do it.

 

How long does it take to figure out one's ratio ? Should I do it a couple of days or longer ?

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JohnSchroeder

Yes, you increase your Lantus until you get the fasting BG levels you want.

 

I think a few of us have said this, and taken literally it could lead you wrong.  At least in my understanding the point is to have your fasting BG levels be STEADY, not necessarily what you want.  Meaning if you go to bed with a BG of 200 and wake up somewhere close to 200, your basal levels are correct.  If you go from 100 to 100, its correct too.

 

You just don't want it to be significantly changing when you are fasting.  And also your BG isn't going to be exactly the same when you get up.. but as long as its ballpark where it was when you went to bed you're good.  100 to 100 +/- 20 or 25 points would be good in my book.  Other people might be more stringent.

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Hammer

Hammer, how do you determine how much to take for a corrective dose ? I did buy some glucose tabs just in case. 

 

So today I will be checking 2 and 4 hours after meals to see how Novolog acts on me. I wish I could eat the same things everyday but I just can't do it.

 

How long does it take to figure out one's ratio ? Should I do it a couple of days or longer ?

The corrective dose is determined by experimenting.  Since we all react differently to meds, you'll need to try taking one unit if your BG levels are too high and see how that affects you.  Once you see how much that one unit drops you, you can roughly estimate how much two or more units should drop you.  The idea is to err on the side of caution and to use a small dose at first.

 

Determining your I:C ratio should only take a few days, since you're testing and adjusting you dose with every meal.  If you eat three meals a day, then you'd have tested and made adjustments three times that day.  Obviously, you could do it over more days, so whatever you are comfortable with is what you should do.

 

You don't have to eat the same foods every day like I do, the thing is, if you eat chicken today, you can note how that affected your numbers, and make a note of it.  Once you find if you need to use insulin for chicken and by how much, weeks can go by before you eat chicken again, but referring to your notes, you'll see how much insulin you took in the past, so you'll know how much to dose each time you eat chicken, or any other food.

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Hammer

I think a few of us have said this, and taken literally it could lead you wrong.  At least in my understanding the point is to have your fasting BG levels be STEADY, not necessarily what you want.  Meaning if you go to bed with a BG of 200 and wake up somewhere close to 200, your basal levels are correct.  If you go from 100 to 100, its correct too.

 

You just don't want it to be significantly changing when you are fasting.  And also your BG isn't going to be exactly the same when you get up.. but as long as its ballpark where it was when you went to bed you're good.  100 to 100 +/- 20 or 25 points would be good in my book.  Other people might be more stringent.

What you said is partly true....that you want you fasting BG levels to be steady, but no, if you go to bed at 200, you don't want to wake up at 200.  If you wake up at 200, you need to increase your basal insulin until you get that fasting BG to under 100.(in my case, in the 70's).  If you got your fasting BG levels to under 100, in my case, in the 70's, then when you go to bed, if you haven't eaten for a number of hours, your bedtime BG should be close to 100, since that is your fasting BG.  If your morning BG is 100, and your bedtime BG is 200, then you didn't take enough Novolog with your last meal, if you did, you wouldn't be at 200.  Once you get your BG down to the level you want, THEN you need to try to maintain that level.  Having a fasting BG of 200 is way too high, so you need to bring that down to a more normal level with your basal insulin, like Lantus.

 

I should mention that my way of dosing insulin is for a type 2 diabetic, not a type one.  While there may be some similarities for both, type 1 diabetics have a different BG range that they try to stay in.  They typically don't want to drop under 100, and they use a lot less insulin than type 2's require.

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